1. Maternal & Child Health and Smoking
Your name, institution, etc. here
YOUR LOGO HERE (can paste to each slide)

2. …dedicated to eliminating children’s exposure to tobacco and secondhand smoke
These slides are provided courtesy of the American Academy of Pediatrics Julius B. Richmond Center of Excellence. The Academy received a grant from the Flight Attendant Medical Research Institute (FAMRI) in 2006 to plan and establish a Center of Excellence dedicated to the elimination of children's exposure to tobacco and secondhand smoke. The Richmond Center was established to help institutionalize pediatric tobacco control activities at the AAP and was named in honor of Julius B. Richmond, MD, Chair of the FAMRI Medical Advisory Board, and former Surgeon General of the United States. Dr. Richmond, a pediatrician and founding director of the Head Start Program, was a fierce advocate for child health, and was also known for developing and implementing the Healthy People goals. FAMRI was born out of a class action law suit brought on behalf of non-smoking flight attendants by Florida attorneys Stanley and Susan Rosenblatt in October 1991 in Dade County Circuit Court against the tobacco industry. The suit brought damages for diseases and deaths caused to non-smoking flight attendants from exposure to second hand tobacco smoke in airline cabins.
Among other considerations, the settlement included the establishment of a not-for-profit medical and scientific research foundation with funding by the tobacco industry of $300 million.

3. Objectives
Discuss fetal/newborn and maternal risks of maternal tobacco use
Identify who is at greater risk of smoking during pregnancy and to identify some of the unique issues of pregnancy
Acquire knowledge about pharmacotherapy and its role in smoking cessation in pregnancy
Provide a brief smoking cessation intervention during pregnancy and post partum period
The risks to the mother and the fetus will be discussed along with what women are at greatest risk for smoking in pregnancy. The benefits and risks of pharmacotherapy will be presented as well as how to provide a brief intervention and what resources are available to pregnant women who are interested in learning more about how to quit smoking

4. The Evidence Is Clear!
When a woman quits smoking during pregnancy, her chances of having an uncomplicated pregnancy and healthy baby are dramatically increased

5. Risks for Women Who Smoke
Reproductive health problems
Infertility
Conception delay
Pregnancy complications
Menstrual irregularity
Earlier menopause
Compromised immune system
Respond differently to nicotine
Cancer
Less likely to breast feed
Osteoporosis
Thrombosis with use of oral contraceptives
CITATION:
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.

6. Prenatal/Neonatal Outcomes
Miscarriage
Fetal death
Pre-term deliveries
Low birth weight baby
Ectopic pregnancies
Placenta previa and placental abruption
SIDS
Birth Defects (cleft lip/palate, heart defects, webbing)
CITATION: Centers for Disease Control and Prevention. (2004). Smoking During Pregnancy-- United States, Morbidity and Mortality Weekly Report, 53(39)

7. “Smoking is the most modifiable risk factor for poor birth outcomes”
A Call to Action:
“Smoking is the most modifiable risk factor for poor birth outcomes”

8. 2008 CPG Recommendation
“Because of the serious risk of smoking to the pregnant smoker and fetus, whenever possible smokers should be offered person-to-person psychosocial interventions that exceed minimal advice”
CITATION:
Fiore M.C., Jaén, C.R., Baker, T.B., et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

9. 2008 CPG Recommendation
Although abstinence early in pregnancy will produce
greatest benefits to the fetus and expectant mother,
quitting at any point in pregnancy can yield benefits…
clinicians should offer effective interventions
at first prenatal visit as well a throughout the pregnancy
CITATION:
Fiore M.C., Jaén, C.R., Baker, T.B., et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

10. Intervention Makes a Difference
Smoking cessation intervention by clinicians improves quit rates
Brief counseling (5 to 15 minutes total) can help many pregnant smokers quit
A woman is more likely to quit smoking during pregnancy than at any other time in her life
Obstetricians and other prenatal care clinicians are uniquely positioned to apply behavioral strategies that will help women quit smoking.
Behavioral interventions lasting from 5 to 15 minutes, delivered by a clinician and supplemented with pregnancy-specific self-help materials, significantly increased smoking cessation rates among pregnant smokers.
Pregnancy is a prime “teachable moment” in health care. Women are more likely to quit smoking during pregnancy than at any other time in their lives. Clinicians can tap into that motivation to help their patients achieve long-term healthy lifestyle changes for themselves and their families.
CITATION:
U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.
Melvin, C.L., Dolan-Mullen, P., Windsor, R.A., Whiteside, H.P. Jr, Goldenberg, R.L. (2000). Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tobacco Control , 9(suppl III):iii80–iii84.
Mullen, P.D. (1999). Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Primary Care, 26(3),

11. Smoke Free Families What we knew in 2000 has stood the test of time
For light to moderate smokers, extended or augmented counseling increases the likelihood of cessation
The components of extended counseling are still supported
Many enhancements have been tested but none have produced results compelling enough to power a change in recommendations
CITATION:
Melvin, C. & Gaffney, C. (2004). Treating nicotine use and dependence of pregnant and parenting smokers: An update. Nicotine and Tobacco Research, 6(S2), S101-5.

12. Teachable Moments Before, During and Beyond Pregnancy
Preconception Care
All Gynecology and primary care visits
Help her quit during pregnancy
Never too late to quit
Smoke free home and car during pregnancy
Smoke free public places and work place
Avoid secondhand smoke
3rd trimester begin post partum discussion
What are her intentions post partum?

13. Pregnancy: A Unique Time
Often more open to change
May have more support to quit while pregnant
May not be socially acceptable to smoke if pregnant
Excited, ambivalent, afraid
May have more stress if unplanned pregnancy
May have added financial burden even if planned

14. Post Partum Opportunities
Prepare for post partum triggers, cues, depression
Intervention during hospital stay
Home visitors
First pediatric appointment
WIC
Follow-up call by quit line or other counselors
Post partum checkup
Smoke free home and car

15. Counseling Intervention
5 As A
efer
sk about tobacco use
dvise to quit
ssess willingness
ssist in quit attempt
rrange for follow-up A A A R A
Community Resources
1-800-QuitNOW

16. sk: About Tobacco Use A
Ask or verify responses in a non-judgmental way:
Identify smoking status
Counsel all smokers and recent quitters
Ask about Household and work environment
Discuss effects of SHS
If they smoke assess
Nicotine dependence
Patterns of use
Past quit attempts

17. Ask Which of the following statements
best describes your cigarette smoking?
I have never smoked or have smoked fewer than 100 cigarettes in my lifetime
I stopped smoking before I found out I was pregnant and am not smoking now
I stopped smoking after I found out I was pregnant and am not smoking now
I smoke some now but have cut down since I found out I am pregnant
I smoke about the same amount now as I did before I found out I was pregnant
Advise
Congratulate
patient
Asking the patient about her smoking status at her initial visit is the first 5 A’s step. Whether you interview the patient or ask her to complete a written history form, structured multiple-choice questions correlate better with biologic markers than simply asking the patient if she smokes and, if so, how much. The multiple choice format has been tested and found to improve disclosure rates by as much as 50% in women across a broad spectrum of racial and socioeconomic backgrounds.
A patient who spontaneously quit after she found out she was pregnant is at high risk for relapse. Reinforce her decision to quit by congratulating her and reminding her how she is helping her baby.
If the patient is still smoking, move on to the second 5 A’s step: Advise.
CITATION:
Dolan-Mullen, P., Ramirez, G., Groff, J. (1994). A meta-analysis of randomized trials of prenatal smoking cessation interventions. American Journal of Obstetrics and Gynecology, 171(5), 1328–34.
Melvin, C., Dolan-Mullen, P., Windsor, R., Whiteside, H. Jr, Goldenberg, R. (2000). Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tobacco Control , 9(S3), iii80–iii84.

18. ssess: Willingness to Make a Quit Attempt
Assess patient’s level of interest in quitting and intention to take action to quit
Ask key questions

19. Importance and confidence scales
“On a scale from 1 to 10, how important is it to you to quit smoking, where 1 is that it is not important at all and 10 is that it is very important.”
CITATION:
Miller, W.R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York, NY: Guilford Publications.
10=very important
1= not important

20. Importance and confidence scales
“On a scale from 1 to 10, how confident are you that you could quit if you tried?”
CITATION:
Miller, W.R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York, NY: Guilford Publications.
1= not confident
10=very confident

21. A ssist: in Quit Attempt Preparation Stage (Willing to quit)
Help the patient with a quit plan
Provide practical counseling
Provide social support
Social support with treatment (Intra-treatment)
Social support outside treatment (Extra-treatment)
Provide supplemental materials (Self-learning materials, quitline, groups)
Your plan may consist of;
Ideally for you to do counseling or some sites can refer to an on-site cessation counselor
Use the (blue) magazine (pages 8-15) Steps to quitting along with Prenatal Quit Plan Tear off Sheet (30/folder-non pregnant, B-123,manual)
Quitline – at a minimum for sites who do not have time to counsel and so not have an on site cessation counselor you can do a quick assist by referring patients to the Quitline
Do Quitline slides
Bring back for follow-up visit no matter what stage they are in

22. 2008 CPG statement and pharmacotherapy in pregnancy
Safety is not categorical. A designation of “safe” reflects a conclusion that a drug’s safety outweigh its risks. Nicotine most likely does have adverse effects on the fetus during pregnancy.
Although the use of NRT exposes the pregnant women to nicotine, smoking exposes them to nicotine plus numerous that are injurious to the fetus other chemicals. These concerns must be considered in the context of inconclusive evidence that cessation medications boost abstinence rates in pregnant women.
CITATION:
Fiore M.C., Jaén, C.R., Baker, T.B., et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

23. Pharmacotherapy and Pregnancy
“If the increased likelihood of smoking cessation, with its potential benefits, outweighs the unknown risk of nicotine replacement and potential concomitant smoking, nicotine replacement products or other pharmaceuticals may be considered.”
CITATION:
American College of Obstetrics and Gynecologists. (2005). ACOG Committee Opinion No. 316: Smoking cessation during pregnancy. Obstetrics and Gynecology, 106(4),

24. Personalized Plan for Patients
Note: Most materials available in Spanish

25. Patients Who Decline to Quit: Using the 5 Rs
Relevance
Risks
Rewards
A patient who declines to make a quit attempt may have reasons for not quitting that she is unable or unwilling to express. Or, she may think smoking risks do not apply to her. The 5 R’s are useful for identifying issues that are of most concern to the patient who is reluctant to try to quit. Motivational interventions are most likely to be successful when the clinician is empathetic, promotes patient autonomy (ie, choice among options), avoids arguments, and supports the patient’s self-efficacy—for example, by reminding her of previous successes in behavior change efforts. It is not necessary to cover all of the 5 R’s at each patient visit.
CITATION:
Miller, W.R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York, NY: Guilford Publications.
Prochaska J, Goldstein MG. (1991). Process of smoking cessation: Implication for clinicians. Clinics in Chest Medicine, 12,
Roadblocks
Repetition

26. 5 Rs: Relevance (importance)
Ask patient to identify how quitting might be personally relevant, such as:
Relevant to her as a women
Relevant to pregnancy
Relevant to unborn child
Relevant to baby after birth
Relevant to money ?
Relevance. Encourage the patient to discuss why quitting might be personally relevant. This will help her link the motivation to quit to her situation. Some suggestions include the presence of children in her home, cost of smoking, or a history of frequent respiratory illness in herself or her family members.

27. Pros and Cons
Good things about Smoking vs
Bad Things about Smoking

28. Hard things about quitting
Pros and Cons
Hard things about quitting vs
Benefits of Quitting

29. 5 Rs: Risks Ask, “What have you heard about smoking during pregnancy?”
Reiterate benefits for her unborn baby and her other children
Reiterate benefits to her
Tell her that a previous trouble-free pregnancy is no guarantee that this pregnancy will be the same
Risks. Make sure that the patient understands the risks of continued smoking by asking her what she considers to be potential negative consequences. One way to begin this part of the discussion is to ask, “Although you do not want to or are not ready to quit now, what have you heard about smoking during pregnancy?” If the patient seems unaware of the risks, this is a good time to give her pregnancy-specific information about risks.

30. 5 Rs : Rewards Your baby will get more oxygen after just 1 day
Your clothes and hair will smell better
You will have more money
Food will taste better
You will have more energy
You will be healthier
Rewards. Ask the patient to identify benefits of quitting smoking. Depending on her situation, she may need some direction, such as “Your clothes and house will smell better,” or “You’ll set a good example for your children and their friends.”

31. 5 Rs : Roadblocks Negative moods Being around other smokers
Triggers and cravings
Time pressure
Stress in her life
Roadblocks. Most patients can readily identify barriers to quitting, giving you the opportunity to address them and to reassure the patient that assistance and encouragement are available. She needs to know that roadblocks such as withdrawal symptoms, weight gain, another smoker in the house, and emotional consequences can be overcome. Problem-solving strategies and tools can be applied to many situations once roadblocks are identified.

32. Overcoming Roadblocks: Negative Moods
Engage in physical activity
Express yourself (write, talk)
Stress reduction/ relaxation
Seek help with other psychological or social issues
Think about pleasant, positive things
Ask others for support
Hard candy: Because they keep the mouth occupied, fat-free hard candies are good substitutes for a cigarette, assuming no dietary restrictions against sucrose. The sugar boost can counter negative emotions.
Physical activity: Walking, housework, going shopping, or gardening can direct thoughts away from negative emotions.
Self-expression: Writing down feelings, talking with a friend, or just expressing feelings out loud in private are a few ways to release negative emotions and prevent their accumulation.
Relaxation: A hot bath or shower, soothing music, deep breathing, meditation, or stroking a pet all diffuse negative feelings.
Redirect negative thoughts: Thinking about a good time, an accomplishment, or anything enjoyable or funny can change a bad mood.
Support system: Make friends and family aware that this is a difficult time, prepare them for occasional moodiness or irritability, and ask for help with routine tasks.

33. Overcoming Roadblocks: Other Smokers
Ask a friend or relative to quit with you
Ask others not to smoke around you
Assign nonsmoking areas
Leave the room when others smoke
Keep hands and mouth busy
Trying to quit when a household member smokes or when social or work activities permit smoking increases the risk of relapse. Strategies for dealing with other smokers depend on who the other smoker is and how comfortable the patient feels asking that person to modify his or her behavior to help support her decision to quit. Only the patient can make the decision about how she would like to prepare to be around other smokers. Choices range from asking a member of the household to quit to asking that person to step outside to smoke. A woman who socializes with smokers may ask others not to smoke around her for the benefit of the baby. If she is uncomfortable making that request, she can leave the area where people are smoking or distract herself with some preplanned activity to keep her hands busy.

34. Overcoming Roadblocks: Triggers and Cravings
Cravings will lessen within a few weeks
Anticipate “triggers”: coffee breaks, social gatherings, being on the phone, waking up
Change routine—for example, brush your teeth immediately after eating
Distract yourself with pleasant activities: garden, listen to music
The craving for a cigarette is part of the nicotine withdrawal picture, and will lessen within a few weeks. The patient can be counseled to anticipate situations when cravings will be strongest, or that she most strongly associates with smoking, and prepare for them. At a social gathering, she might keep her hands and mouth busy with raw vegetables, or by assisting the host with serving and clean-up. If she habitually smokes upon waking up, she might consider changing her morning routine.

35. Secondhand Smoke

36. The Debate Is Over
“The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.”
U.S. Surgeon General Richard H. Carmona in a News Release for the 2004 Surgeon General Report, The Health Consequences of Smoking.

37. What is secondhand smoke?
Secondhand Smoke (SHS) is the smoke that comes off the end of a smoking cigarette and the smoke that the smoker exhales
CITATION:
Harlap, S., Davies, A.M. (1974). Infant admissions to hospital and maternal smoking. Lancet, 1(7857),

38. The Health Effects of Tobacco Use
Asthma
Otitis Media
Fire-related Injuries
Influences
to Start
Smoking
SIDs
Bronchiolitis
Meningitis
Childhood
Infancy
Adolescence
Nicotine Addiction
In utero
Adulthood
CITATION:
Aligne, C.A., Stoddard, J.J. (1997). Tobacco and Children: An Economic Evaluation of the Medical Effects of Parental Smoking. Archives of Pediatrics & Adolescent Medicine, 151(7),
Low Birth Weight
Stillbirth
Neurologic Problems
Cancer
Cardiovascular Disease
COPD

39. Secondhand smoke is toxic: 4000 chemicals
> 50 Cancer-causing chemicals
Formaldehyde
Benzene
Polonium
Vinyl chloride
Toxic metals:
Chromium
Arsenic
Lead
Cadmium
Poison Gases:
Carbon monoxide
Hydrogen cyanide
Butane
Ammonia
CITATION:
National Toxicology Program. Report on Carcinogens. Eleventh Edition. U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program, 2005.

40. SHS and Children: Short Term Health Effects
Respiratory tract infections such as pneumonia & bronchitis
Decreased pulmonary function
Triggers asthma attacks
Ear Infection (Otitis Media)
Tooth decay
House fires
CITATION:
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.

41. SHS and Children: Long Term Health Effects
Sudden Infant Death Syndrome (SIDS)
Asthma
SHS exposure increases frequency of episodes and severity of
symptoms
200,000 annual cases of childhood asthma, attributed to SHS
Possible problems with cognitive functioning and behavioral development
More likely to become smokers
CITATION:
Farber, H.J., Knowles, S.B., Brown, N.L., et al. (2008). Secondhand tobacco smoke in children with asthma: sources of and parental perceptions about exposure in children and parental readiness to change. Chest, 133(6),

42. SHS and Adult Health Risks
Nonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing;
Lung cancer (20-30%)
Coronary heart disease (25-30%)
Acute respiratory problems
CITATION:
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.

43. Case Study: Sylvia Pregnant with first baby 19-year old
One prior quit attempt for a few days
Interested in effects on baby and children
19-year old
Smokes 16 cigarettes a day for past 3 years
Fights frequently with husband
1. Ask about smoking status using a health history or survey.
2. How will you Advise with a clear, strong, personalized message to quit smoking?
3. Assess the patient’s stage of readiness to quit.
4. To Assist her in making a quit plan what might you include?
5. What barriers or concerns about quitting would you address and would you do this?
6. Arrange for follow-up via appointment, telephone, or referral.
7. Document the intervention in the patient chart.

44. Case Study: Lisa 17-year old
6 months pregnant, admitted to hospital for pre-term labor
Smokes a pack & a half a day and has smoked for 6 years
Boyfriend smokes
Hospitalized 4 days & medicated to stop contractions
Contraction free & being discharged
Enjoys smoking & has no interest in quitting
1. Ask about smoking status using a health history or survey.
2. How will you Advise with a clear, strong, personalized message to quit smoking?
3. Assess the patient’s stage of readiness to quit.
4. To Assist* her in making a quit plan what might you include?
5. What barriers or concerns about quitting would you address and would you do this?
6. Arrange for follow-up via appointment, telephone, or referral.**
7. Document the intervention in the patient chart.

45. Case Study: Linda 27 years old
3 children ages 6,4, and 2 who have asthma
Smokes 1 pack of cigarettes a day
Has smoked for 14 years
Expresses little interest in quitting
1. Ask about smoking status using a health history or survey.
2. How will you Advise with a clear, strong, personalized message to quit smoking?
3. Assess the patient’s stage of readiness to quit.
4. To Assist* her in making a quit plan what might you include?
5. What barriers or concerns about quitting would you address and would you do this?
6. Arrange for follow-up via appointment, telephone, or referral.**
7. Document the intervention in the patient chart.
* Discuss SHS risk for children especially child with Asthma
* Discuss smoke Free Home , Care, and Daycare
* Remember to discuss pharmacotherapy if appropriate
**Refer to the Quitline (1-800-QUITNOW) and/or community resources

46. Case Study: John Had several prior quit attempts 32-year old father
Occasionally uses smokeless
tobacco instead of cigarettes
Wife encourages him to quit
Not sure about trying again
32-year old father
Smokes a pack a day for past 14 years
John is sick with bronchitis
Has a son who has asthma
Concerned about stress with work & home life and avoiding weight gain
1. Ask about smoking status using a health history or survey.
2. How will you Advise with a clear, strong, personalized message to quit smoking?
3. Assess the patient’s stage of readiness to quit.
4. To Assist* him in making a quit plan what might you include?
5. What barriers or concerns about quitting would you address and would you do this?
6. Arrange for follow-up via appointment, telephone, or referral.**
7. Document the intervention in the patient chart.
*Remember to discuss pharmacotherapy if appropriate **Refer to the Quitline (1-800-QUITNOW) and/or community resources

47. Case Study: Grace 55-year old women Has emphysema
Smokes a pack a day for the past 30 years
Has tried to quit several times in the past
Daughter and grandson lives with her
1. Ask about smoking status using a health history or survey.
2. How will you Advise with a clear, strong, personalized message to quit smoking?
3. Assess the patient’s stage of readiness to quit.
4. To Assist* him in making a quit plan what might you include?
5. What barriers or concerns about quitting would you address and would you do this?
6. Arrange for follow-up via appointment, telephone, or referral.**
Document the intervention in the patient chart.
*Remember to discuss pharmacotherapy if appropriate
**Refer to the Quitline (1-800-QUITNOW) and/or community resources

48. Need more information? The AAP Richmond Center
Audience-Specific Resources
State-Specific Resources
Cessation Information
Funding Opportunities
Reimbursement Information
Tobacco Control List
Pediatric Tobacco Control Guide